'Uber for Birth Control' Faces Battle from Conservatives

App delivers morning after pill with a few clicks

It's a telemedicine app that seems rather innocuous -- enter your info, have it reviewed by a physician, and get a prescription. The California-based company behind it has raised millions to support its mission of expanding access to the pill, ring, or morning-after pill with minimal hurdles.

But that last option is now starting to attract pushback from anti-abortion activists, who consider the morning-after pill equivalent to abortion -- and who say lax telemedicine laws are enabling access to this drug with insufficient oversight.

Nurx, an app that's been called the "Uber for birth control," lets patients obtain a variety of contraceptives from the touch of a smartphone; it also gives women access to Plan B and Ella, two forms of the morning-after pill, which is effective in preventing a pregnancy after sex. Women can order these drugs in a few easy steps: answer a series of health questions; provide basic demographic information; and choose a preferred drug. A doctor then reviews the patient's information, writes a prescription, and the drug is delivered to either the patient's home or her local pharmacy.

Over the past two years, Nurx's founders have made the app available in 15 states plus Washington D.C., and they have ambitions to expand nationwide. But as the app has been rolled out in conservative states, activists have become increasingly vocal in opposing a drug they believe is ending life at its earliest stages.

"You usually have a pharmacist, licensed facilities, and an administrator double-checking guidelines" for women getting emergency contraceptives, said John Seago, legislative director for Texas Right for Life.

But the consensus of the majority of health experts is that emergency contraceptives are safe, and that their mechanism of action is, in fact, different from the abortion pill.

That divide is now coming to the fore, as activists in some conservative states are pressing lawmakers to more tightly regulate emergency contraception prescribed by app.

'Brewing a storm where there's nothing'

Much of the fight hinges on a particularity of how the morning-after pill was dispensed before Nurx came along. The Food and Drug Administration has approved a popular brand, Plan B, for over-the-counter sale in all states for women who pay out of pocket. But if a woman is using her insurance benefits to cover the drug, she'll typically need a prescription for Plan B. And a newer emergency contraceptive, Ella, is only available with a prescription. The app, then, short-circuits this divide and lets insured women easily get the morning-after pill in a way more akin to the over-the-counter interaction.

Looked at this way, said Nurx co-founder Hans Gangeskar, activists are "brewing a storm where there's nothing."

The app is also expanding access to emergency contraceptives at a time when various states are creating roadblocks to obtain the morning-after pill. The Guttmacher Institute has found that at least nine states have adopted restrictions to make it harder for residents to obtain emergency contraceptives, from excluding the drug from contraception coverage mandates to giving pharmacists the right to not dispense contraceptives.

A driving force for these state efforts has been the idea that emergency contraceptives are abortion-causing drugs. That claim played a central role in Hobby Lobby's U.S. Supreme Court victory in which the company's owners had religious objections to covering contraceptives. And Seago points to specific language from the FDA's labeling that says both drugs can inhibit an embryo from implanting to a uterine wall. It's wording that's led people like Susan Klein, executive director of Missouri Right to Life, to consider emergency contraceptives on the same level as the abortion pill RU 486 -- even though FDA classifies Plan B and Ella as contraceptives.

"We believe life begins at fertilization," Seago said. "That's the point where we have an individual, and morally that's who we want to protect."

Tami Fitzgerald, the executive director of the NC Values Coalition, a group that advocates for "pro-family" stances, said she is more troubled by the fact that a minor can use Nurx to obtain emergency contraceptives without a parent's knowledge. (Nurx defers to state laws surrounding minimum age for birth control prescriptions but itself only bars those under age 12 from applying.) That "contravenes the right of parents to be involved in something as intimate and dangerous as taking a pill that induces abortion," Fitzgerald said.

But the view Fitzgerald and Klein hold -- that emergency contraceptives and the abortion pill work similarly -- is out of step with science, according to Susan Wood, an associate professor of health policy at George Washington University. They assume that "a fertilized egg is the same as pregnancy and is the same as a person," Wood said. She says that's simply not the case because about half of fertilized eggs never implant in the uterus. "A woman is not pregnant until the egg is implanted and stabilized," Wood said.

Moreover, Wood said the FDA hasn't updated its labeling to remain in line with evidence that now shows emergency contraceptives prevent the sperm from fertilizing the egg in the first place.

"Their argument that there's some lost fertilized egg -- and calling that an abortion -- isn't even happening," she said.

Dr. Jessica Knox, a preventive medicine physician who serves as medical director for Nurx, noted that people who get prescribed Plan B through the app are actually getting more medical attention from a health professional compared to buying the drug over the counter. Because of that, Nurx is "adding a barrier" in the sense that the company vets patient info, asks follow-up questions if needed, and offers counseling. She feels that Nurx, in that regard, is going above and beyond in caring for women.

Appealing to state lawmakers

In advance of legislative sessions next year, anti-abortion activists are now mulling how to get the issue of telemedicine prescribing on state lawmakers' agendas.

In North Carolina, Fitzgerald said her group hopes Nurx will get reviewed as part of a previously planned study of the state's telemedicine laws. Lawmakers are eventually supposed to produce a report on with recommendations for changes to how care is delivered online, including drug prescribing, licensing, and reimbursement standards. Fitzgerald hopes the findings of the report lead to tougher regulations for Nurx.

Lawmakers say the app has been brought up by name. "I have had other lawmakers talk to me about [the way Nurx is used to obtain the morning-after pill]," North Carolina state Rep. Donny Lambeth, a Republican who co-sponsored legislation to review the state's telemedicine laws, told STAT by email. "This will certainly be an issue that we may need to consider."

And Texas Right to Life would also like to see more restrictions on emergency contraceptives available through telemedicine. Though lawmakers haven't taken up the issue yet, Seago foresees them doing so once Nurx lands on their radar.

"This [use of telemedicine] hasn't been fully debated," Seago said. "I think it'll take most lawmakers in conservative states by surprise."

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